I was a role model in all the applicable categories except Customer Service, Finance & Capacity, and Quality & Safety. In order to role model in those categories, the entire Pulmonary Unit must meet or exceed the goals in those areas. The Pulmonary Unit manager, Kaycee provided the entire breakdown for those categories as listed below.
Critical Success Factors for the Pulmonary Unit 2013
Patient Safety:
Falls: Role Model: Goal 3.17falls/1000 patient days. Current score: 1.45
We have consistently done well with a few months over the benchmark, so
we have to watch this with the changing population we face.
High fall risk = bed alarm, no question, it is policy and a legal
nightmare you don’t want to face.
Critical Labs: Below Standards Goal 85% compliance. Current score: 80.625%
We have improved this due to Molli’s education (most recent
score 90%). Most common problem is that the time stamp for your documentation does not imply the time you called the MD/Received the call, so making sure to input the time called/received is imperative to improve this score.
Finance and Capacity:
Sick Calls/Tardies/Overtime: James had no sick calls = role model
One notice of 2 sick calls/90 days=Successful
More than 2 notices of 2 sick calls or 3 sick calls in 90 days=Below Standards
No notices: Role model
Productivity: Below Standards Goal: 100% Current Score: 95.2%
This one is tough because we had a lot of variable factors that aren’t
necessarily staff controlled, BUT the one area we can all work together to
improve this is by keeping overtime and admin time to a minimum.
Right now, making sure to continue compliance with LOOK report by
documenting change of shift report at the beginning of your shift (rather than
the end) and ensuring only one rep from the floor is attending committee
meetings (if shared with multiple members). Another way to help is to make sure to input start/stop times on all OBS patients.
Discharge by 2: Successful Goal: 50% Current Score: 56.3%
This requires teamwork and foresight of the nurses where you need to
plan for and address potential barriers before 2pm, so that once you have the orders they can be discharged quickly. Another goal would also be updating the milestones on the bedboard/teletracking to communicate delays and timing hospital wide. CNA’s and PSC’s should also be your resource to input these milestone updates.
Clean to Occupy time: Successful Goal: 50% arrive within 1 hour
Current Score: 59.6%
When a patient is admitted to a clean bed, getting the patient in that bed within one hour of being assigned. That means calling the ED or the transferring department to meet this goal is expected. Keep up the good work because I know there are a lot of variables that affect achieving this goal.
Unit Predictions at or above 60% per teletracking: Successful Current: 87.6
This one is really reliant on updating your charge nurse if your patient is going home, and then your charge nurse pending the discharge. This helps the hospital immensely by decreasing ‘surprise’ discharges. This is where communication is key, and you all have done a fantastic job!!
PAR excellence tapping: not on eval this year but add it since we are finally Successful. Goal: 90% Current score: 91% (last year below!)
Excellent improvement. Keep in mind we will have 2 in the future so this will continue to require us to be vigilant. Also know that tapping is not ‘charging’ the patient, it is more of an inventory tracking tool (so we refill appropriately).
Customer Service: If any staff member gets a below
standards individually on , they cannot role model for the final evaluation.
HCAPS: Role Model Goal: 75% for Succ, >75% for Role Model
Current: 85.7% -Currently the BEST in the HOSPITAL!!!
This is FANTASTIC, and you all should be so proud to be so highly regarded by those that you serve everyday. Not many units have hit the mark on this, and you all have done a great job. Hourly rounding and responsiveness to calls appear to be a huge factor so make sure you continue this practice.
One potential goal: choose one patient every shift that you are going to go above and beyond for, and see how it makes you feel, as well as your
patient. Let’s continue the passion for taking excellent care of patients that prompted you to go into healthcare in the first place.
Responsiveness of Staff: Role Model. Baseline last year: 63.9%
Target for this year: 67.1 Unit Score: 71.59%
This has been incredible! And a lot to do with Staci’s projects with the phone and hourly rounding. The month of the hourly rounding rollout we hit the 99th percentile which means we ranked the highest out of all the nation's hospitals in this category! But I will be honest our scores are slipping, so make sure hourly rounding is done with presence-take time to really listen and look at your patient during hourly rounding.
Pain Management: Below Standards Baseline last year: 84.8%
Target for this year: 89% Unit Score: 79%
This is disappointing, but we started with a very high rating, so very difficult to maintain. This is a brand new goal, but so very important to both patient and nurse/CNA satisfaction. With hourly rounding, CNA’s need to ensure they know they should be asking about pain control to advocate and show the team effort to our patients and that we care. Reassessment needs to be checked and documented (by RN) within one hour. Using whiteboards to detail when the next pain med would be due is a good patient satisfier as well as communicates to the CNA for that team approach.
Discharge information: Successful
Baseline last year: 70.8% Target for this year: 74.3% Unit Score: 81.19%
Good job improving the discharge process. One thing to note though is that this area is still in the 10th percentile for the nation, so that means 90% of hospitals are doing better than us, so focusing on how to improve our discharge process will be a goal for Pulmonary this year.
Critical Success Factors for the Pulmonary Unit 2013
Patient Safety:
Falls: Role Model: Goal 3.17falls/1000 patient days. Current score: 1.45
We have consistently done well with a few months over the benchmark, so
we have to watch this with the changing population we face.
High fall risk = bed alarm, no question, it is policy and a legal
nightmare you don’t want to face.
Critical Labs: Below Standards Goal 85% compliance. Current score: 80.625%
We have improved this due to Molli’s education (most recent
score 90%). Most common problem is that the time stamp for your documentation does not imply the time you called the MD/Received the call, so making sure to input the time called/received is imperative to improve this score.
Finance and Capacity:
Sick Calls/Tardies/Overtime: James had no sick calls = role model
One notice of 2 sick calls/90 days=Successful
More than 2 notices of 2 sick calls or 3 sick calls in 90 days=Below Standards
No notices: Role model
Productivity: Below Standards Goal: 100% Current Score: 95.2%
This one is tough because we had a lot of variable factors that aren’t
necessarily staff controlled, BUT the one area we can all work together to
improve this is by keeping overtime and admin time to a minimum.
Right now, making sure to continue compliance with LOOK report by
documenting change of shift report at the beginning of your shift (rather than
the end) and ensuring only one rep from the floor is attending committee
meetings (if shared with multiple members). Another way to help is to make sure to input start/stop times on all OBS patients.
Discharge by 2: Successful Goal: 50% Current Score: 56.3%
This requires teamwork and foresight of the nurses where you need to
plan for and address potential barriers before 2pm, so that once you have the orders they can be discharged quickly. Another goal would also be updating the milestones on the bedboard/teletracking to communicate delays and timing hospital wide. CNA’s and PSC’s should also be your resource to input these milestone updates.
Clean to Occupy time: Successful Goal: 50% arrive within 1 hour
Current Score: 59.6%
When a patient is admitted to a clean bed, getting the patient in that bed within one hour of being assigned. That means calling the ED or the transferring department to meet this goal is expected. Keep up the good work because I know there are a lot of variables that affect achieving this goal.
Unit Predictions at or above 60% per teletracking: Successful Current: 87.6
This one is really reliant on updating your charge nurse if your patient is going home, and then your charge nurse pending the discharge. This helps the hospital immensely by decreasing ‘surprise’ discharges. This is where communication is key, and you all have done a fantastic job!!
PAR excellence tapping: not on eval this year but add it since we are finally Successful. Goal: 90% Current score: 91% (last year below!)
Excellent improvement. Keep in mind we will have 2 in the future so this will continue to require us to be vigilant. Also know that tapping is not ‘charging’ the patient, it is more of an inventory tracking tool (so we refill appropriately).
Customer Service: If any staff member gets a below
standards individually on , they cannot role model for the final evaluation.
HCAPS: Role Model Goal: 75% for Succ, >75% for Role Model
Current: 85.7% -Currently the BEST in the HOSPITAL!!!
This is FANTASTIC, and you all should be so proud to be so highly regarded by those that you serve everyday. Not many units have hit the mark on this, and you all have done a great job. Hourly rounding and responsiveness to calls appear to be a huge factor so make sure you continue this practice.
One potential goal: choose one patient every shift that you are going to go above and beyond for, and see how it makes you feel, as well as your
patient. Let’s continue the passion for taking excellent care of patients that prompted you to go into healthcare in the first place.
Responsiveness of Staff: Role Model. Baseline last year: 63.9%
Target for this year: 67.1 Unit Score: 71.59%
This has been incredible! And a lot to do with Staci’s projects with the phone and hourly rounding. The month of the hourly rounding rollout we hit the 99th percentile which means we ranked the highest out of all the nation's hospitals in this category! But I will be honest our scores are slipping, so make sure hourly rounding is done with presence-take time to really listen and look at your patient during hourly rounding.
Pain Management: Below Standards Baseline last year: 84.8%
Target for this year: 89% Unit Score: 79%
This is disappointing, but we started with a very high rating, so very difficult to maintain. This is a brand new goal, but so very important to both patient and nurse/CNA satisfaction. With hourly rounding, CNA’s need to ensure they know they should be asking about pain control to advocate and show the team effort to our patients and that we care. Reassessment needs to be checked and documented (by RN) within one hour. Using whiteboards to detail when the next pain med would be due is a good patient satisfier as well as communicates to the CNA for that team approach.
Discharge information: Successful
Baseline last year: 70.8% Target for this year: 74.3% Unit Score: 81.19%
Good job improving the discharge process. One thing to note though is that this area is still in the 10th percentile for the nation, so that means 90% of hospitals are doing better than us, so focusing on how to improve our discharge process will be a goal for Pulmonary this year.